complaint·October 30, 2025

The facility’s admission agreement stated that individuals who moved out of the facility within 3 months of admission would be entitled to a 40 percent refund of the community fee, minus $500, which amounted to $1,400. Review of R1’s financial ledger and interviews with facility management revealed that a $1,400 refund was processed and refunded in June 2025, which exceeds the time frame set by regulation. The Department has investigated the above-mentioned allegation and based on interview and record review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page. An exit interview was conducted with Executive Director Kristel Johnson , whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 03/22). Review of R1’s physician’s orders in January 2024 revealed that R1 had a medication order for Escitalopram and Amitriptyline which were both ordered on 1/18/2024 and discontinued on 1/31/2024. Review of R1’s needs and services plan and medical assessment dated January 2024 revealed that R1 was unable to administer prescription medication independently and was receiving medication management from facility staff. Review of the facility’s charting notes and faxes sent to R1’s physicians revealed that on 2/12/2024, the Resident Services Director (RSD) notified R1’s physicians via fax that R1 had not been taking Escitalopram and Amitriptyline since 1/30/2024 and requested physician advice on R1 restarting the medications at the previous dose and requested a written physician order for both medications. RSD received written medication orders for Escitalopram on 2/13/2024. RSD reached out to R1’s physicians daily regarding the Amitriptyline medication until the RSD received a written medication order for Amitriptyline on 2/16/2024. Interviews and review of R1’s medication administration record (MAR) revealed that R1 began receiving Escitalopram on 2/14/2024 and Amitriptyline on 2/16/2024. The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has not been met, therefore, this allegation is deemed unsubstantiated. An exit interview was conducted with Executive Director Kristel Johnson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).